Peter House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in continued breach of the legal regulations in relation to safe care and treatment.

The provider was also in breach of the legal regulations in relation to safeguarding.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not demonstrate a proactive and positive culture of learning in order to improve people’s safety. The provider did not have an effective process in place to monitor and review incidents to identify concerns and reduce the risk of a reoccurrence. For example, incidents of physical interventions were not analysed to understand underlying trends and themes. This meant the provider was not exploring what could have been done differently to reduce the risk of a reoccurrence and minimise restrictive practices. Where lessons learnt were documented, these lacked detail and did not demonstrate how learning was being used to improve and embed good practices.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. The provider was not always able to demonstrate how they worked effectively with other health professionals to ensure people’s needs could be safely met prior to their admission into the service. People’s care plan documentation was not always up to date or detailed. This meant staff did not have accurate information about people’s needs to share with other services to ensure people received continuity in their care when moving between services.

The provider did not work well with people and healthcare partners to understand what being safe meant to them. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect.

Where restrictive practices such as physical interventions were being used, the provider had not ensured people’s Deprivation of Liberty Safeguards (DoLS) authorisations were an accurate and up to date reflection of the current interventions in place. This meant the restrictions had not been assessed and authorised to ensure they were necessary and proportionate. Policies and procedures in place in the service demonstrated an over reliance on restrictive practices rather than positive, proactive approaches. The provider was not able to demonstrate how they were reviewing restrictive practices in the service to promote a better understanding of people’s needs and reduce restrictions and incidents of physical intervention.

The provider had not always shared concerns quickly and appropriately with the relevant authorities. During the inspection we found evidence of safeguarding concerns which had not been raised with CQC in line with the provider’s regulatory responsibilities.
 

Risks to people’s health and safety were not assessed and managed appropriately. Risk assessments were not in place for all identified risks. Where risk assessments were in place, these were not always accurate or detailed. Staff did not have adequate guidance to support them in managing risks associated with physical interventions and incidents where people may pose a risk to themselves or others. Staff did not have accurate, detailed guidance about risks associated with people’s eating and drinking needs, choking risks or diabetes care.

People’s personal emergency evacuation plans (PEEPs), detailing how to support them to evacuate safely in the event of a fire, did not contain all relevant information. Not everyone in the service at the time of the inspection had a PEEP in place and we found a PEEP for a person no longer in the building. This meant emergency services would not have accurate information about who was in the building in the event of a fire.

Following our feedback, the provider responded promptly to ensure PEEPs were in place and accurate.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment supported the delivery of safe care. Practice fire evacuation drills were not being completed in line with the provider’s own policy. Fire safety system checks were not being completed as scheduled and fire drill records lacked detail. This meant there was a risk concerns may not be promptly identified and staff may not know how to respond appropriately in case of a fire.

At the last inspection, we identified concerns with the accessibility and condition of the outside environment and the suitability of the indoor environment. The provider had taken action, fully renovating the service and creating individual flats for people instead of shared spaces. At this inspection we found the concerns with the outdoor environment had been addressed.
 

The provider made sure there were enough staff available to support people. Appropriate recruitment policies and processes were in place and staff were safely recruited.

Staff were provided with a range of training. However, we found they had not received all relevant training. For example, staff had not completed training in relation to eating and drinking risks and the management of modified diets despite this being an identified need in the service.

The provider had not always ensured staff had the appropriate skills and competency to support people safely. For example, not all staff had regularly completed practice fire drills or been instructed on use of the fire alarm system.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. During the inspection we found the service was clean, with no significant infection prevention and control concerns identified.

People’s medicines and treatments were safe and met their needs. People’s medicines records were accurate and up to date and staff had recorded the administration of medicines appropriately. The provider had a medicines policy in place and completed regular medicines audits.